INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY
IMPROVING THE RATES OF INPATIENT PNEUMOCOCCAL
VACCINATION: IMPACT OF STANDING ORDERS VERSUS
COMPUTERIZED REMINDERS TO PHYSICIANS
Christina M. Coyle, MD, MS; Brian P. Currie, MD, MPH
Approximately 40,000 deaths are attributed to
Streptococcus pneumoniae infections annually, accounting
for more deaths than any other vaccine-preventable bac-
terial disease.1,2Case-fatality rates are highest for menin-
gitis and bacteremia, with the highest mortality occurring
among the elderly and patients with underlying medical
conditions.3-5Close to half of these deaths could potential-
ly be prevented through the use of pneumococcal vaccine,
given that vaccine effectiveness in case–control studies
has ranged from 56% to 81%.6-10
Despite the availability of a clinically efficacious and
cost-effective pneumococcal vaccine, national vaccination
rates among targeted populations have remained low,
even after the institution of reimbursement incentives.11
Only 45.9% of individuals 65 years or older received the
pneumococcal vaccine in 1997.12
Recent strategies to improve pneumococcal vaccina-
tion rates have included programs that target hospitalized
patients. The potential effectiveness of these programs in
reaching patients most likely to develop pneumococcal dis-
ease is underscored by reports that two-thirds of individu-
als with serious pneumococcal disease had been hospital-
ized during the 4 years prior to their pneumococcal illness,
yet few had received the vaccine.11-16A variety of approach-
es to promote inpatient pneumococcal vaccination have
been implemented, including computerized reminders to
physicians at the time of patient discharge, stamped notes
on hospital charts, vaccination prompts embedded in
pneumonia clinical pathways, and standing orders proto-
Study methodologies and interventions and report-
ed results vary.11None of the most successful immuniza-
tion programs described to date has depended on active
physician participation.11These programs have relied on
nurses or pharmacists to identify patients eligible for
vaccination and a standing orders protocol to
allow physician independent initiation of vaccination.
Vaccination rates have been reported to range from 22% to
94%.13,14,16In contrast, studies that have investigated physi-
cian reminders to vaccinate eligible inpatients with pneu-
mococcal vaccine have reported vaccination rates ranging
from 14% to 44%.18,20,22This investigation was a prospective
The authors are from the Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York. Dr.
Coyle is also from the Division of Infectious Diseases, Department of Medicine, Jacobi Medical Center; and Dr. Currie is also from the Division of
Infectious Diseases, Department of Medicine, Montefiore Medical Center, Bronx, New York.
Address reprint requests to Christina M. Coyle, MD, MS, Division of Infectious Diseases, Department of Medicine, Jacobi Medical Center, Room
3N7, 1400 Pelham Parkway South and Eastchester Road, Bronx, NY 10461.
Presented in part at the 39th Annual Meeting of the Infectious Diseases Society of America; October 25-28, 2001; San Francisco, CA.
OBJECTIVE: To determine the impact of interventions
using standing orders and computerized reminders to physicians
on inpatient pneumococcal vaccination rates relative to a control
DESIGN: Open trial of the following approaches, each on
a different ward: (1) standing orders for vaccination of eligible
consenting patients, (2) computerized reminders to physicians,
and (3) usual practice.
SETTING AND PATIENTS: Four hundred twenty-four
patients were admitted to three 30-bed inpatient medical wards
during a 4-month period in 1999 at one hospital. Unvaccinated
patients 65 years or older and competent to give oral consent
INTERVENTION: A pharmacist activated a standing
orders protocol for vaccination of all eligible consenting patients
on one ward and computerized reminders to physicians on a sec-
ond ward. A third ward served as a control group.
RESULTS: Forty-two patients met inclusion criteria and
accepted vaccination in the standing orders arm versus 35
patients in the computerized reminder arm. Vaccination rates on
the standing orders ward included 98% of those eligible and
accepting vaccination, 73% of eligible patients, and 28% of all
patients admitted. Rates on the computerized reminder ward
were 23%, 15%, and 7%, respectively. All of the rates from the
standing orders ward were significantly greater than those from
the computerized reminder ward (P < .0001). Only 0.6% of all
patients on the control arm were vaccinated.
CONCLUSION: Although both interventions were effec-
tive in increasing inpatient pneumococcal vaccination rates rela-
tive to baseline practice, physician independent initiation of
standing orders was clearly more effective (Infect Control Hosp
Vol. 25 No. 11
IMPROVING INPATIENT PNEUMOCOCCAL VACCINATION RATES
study that compared the impact of two types of interven-
tions (standing orders vs computerized reminders to
physicians) on rates of inpatient pneumococcal vaccination
relative to a control group at a single hospital.
Jacobi Medical Center is a 500-bed municipal teach-
ing hospital of the Albert Einstein College of Medicine.
The hospital and associated on-site ambulatory care clin-
ics are supported by a computerized clinical information
system. The electronic medical record uses computerized
order entries by physicians and archives all patient care
activities, including vaccination orders, from 1995 to the
present. This prospective interventional study was con-
ducted on three separate 30-bed inpatient general medi-
cine teaching wards during a 4-month period in the spring
of 1999. A single ward served as the dedicated site for
each of the two interventional arms, standing orders ver-
sus computerized reminders to physicians, and the third
served as a control group. There was no crossover of
nursing, attending physician, or resident staff between
wards during the study period. This study was approved
by the institutional review board of the Albert Einstein
College of Medicine.
All hospitalized patients 65 years or older who were
competent to give oral consent and had not received
pneumococcal vaccination within the previous 5 years
were eligible for inclusion. Prior vaccination history was
ascertained by querying the clinical information system
and by patient interview. All patients with no computer
record of vaccination and either a negative or unknown
pneumococcal vaccination history were included. Any
patient with a computer record of prior vaccination
greater than 5 years before admission or who gave a his-
tory on interview of pneumococcal vaccination more than
5 years before admission was included. Patients were
excluded if they were unable to give oral consent (due to
dementia, altered mental status, or intubation), if they
had a computer record of pneumococcal vaccination with-
in 5 years of admission, or if they gave a history on inter-
view of pneumococcal vaccination within 5 years of
Pharmacy staff screened all patients on both inter-
vention wards within 72 hours of admission to assess eli-
gibility for study inclusion. Eligible patients were provid-
ed written bilingual educational materials (English and
Spanish), and the contents were reviewed with the patient
prior to offering pneumococcal vaccination. Educational
materials consisted of information sheets prepared by the
Centers for Disease Control and Prevention discussing
the risks and benefits and potential side effects of pneu-
Acceptance or refusal was documented. All patients
were then administered a brief oral questionnaire that
explored previous vaccination experiences regarding per-
ceived side effects, prior history of pneumonia, perceived
individual risk of pneumonia, and the reasons for refusal
of vaccination for those patients who had elected not to be
Patients who accepted vaccination on the computer
reminder arm had a physician reminder entered into the
clinical information system that stated, “Your patient is eli-
gible for and accepted the pneumococcal vaccine. Please
order the vaccine as one 0.5-mL dose IM.” The reminder
appeared in a pharmacy recommendation screen that
users had been trained to review on a daily basis. Patients
who accepted vaccination on the standing orders ward
had a standing order activated in the clinical information
system by the screening pharmacist that authorized pneu-
mococcal vaccination under the physician signature of the
Director of Infectious Diseases.
Patients on the control ward were not approached
or interviewed by pharmacy staff, and pneumococcal vac-
cination occurred as per historical practice patterns.
Healthcare personnel on the control ward did not know
they were serving as the control.
Patients in each arm of the study were analyzed
regarding gender, ethnicity, mean age, and admitting
diagnosis (cardiac, neurologic, and pulmonary disease
Prior rates of pneumococcal vaccination and cur-
rent rates of vaccine acceptance were compared for each
of the two intervention arms, and actual rates of vaccina-
tion were compared for all three study groups. Analysis of
questionnaire results was accomplished by pooling
responses from both intervention wards and then com-
paring responses from patients accepting vaccination with
those refusing it.
Comparisons specifically investigated whether
patients accepting vaccination on the intervention wards
were more likely to have had a prior history of pneumonia
or a self-perception of increased risk for acquiring pneu-
monia relative to patients who refused vaccination.
Statistical comparisons were made with a two-tailed
test of means or a two-tailed chi-square statistic as appro-
Four hundred twenty-four patients were admitted to
the wards during the 4-month study period (147 in the
standing orders arm, 122 in the computerized reminder
arm, and 155 in the control group). There was no statisti-
cally significant difference between groups regarding
mean age, gender, ethnicity, or admitting diagnosis (data
not shown). Thirty-six percent (97 of 269) of the patients
on the intervention wards had prior pneumococcal vacci-
nation histories, and rates of prior vaccination did not dif-
fer significantly between intervention wards (P = .713).
After exclusion criteria were applied, 56 patients in
INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY
the standing orders arm and 55 patients in the computer-
ized reminder arm were screened by the pharmacists.
Excluded patients in the intervention arms had similar
demographics. The overall rate of pneumococcal vaccine
acceptance was 69%: 75% in the standing orders arm and
64% in the computerized reminder arm (P = .194).
Forty-two patients in the standing orders arm
accepted vaccination and 41 were documented to have
received it. Thirty-five patients in the computerized
reminder arm accepted vaccination, but only 8 were doc-
umented to have received it. Only one patient in the con-
trol arm was documented to have received vaccination.
Vaccination rates on the standing orders ward included
98% of those eligible and accepting vaccination, 73% of eli-
gible patients, and 28% of all patients admitted. The rates
on the computerized reminder ward were 23%, 15%, and
7%, respectively. All rates in the standing orders arm were
significantly greater than those in the computerized
reminder arm (P < .0001). In comparison, only 0.6% of all
patients in the control arm were vaccinated, significantly
fewer than those in either intervention arm (P < .0001).
Questionnaire data indicated that patients accepting
pneumococcal vaccination were more likely to perceive
themselves at risk for pneumococcal disease relative to
those who refused vaccination (84.3% vs 16.7% of patients;
P < .0001).
Rates of prior pneumonia infection trended higher
among patients accepting vaccination versus those refus-
ing it, but these differences were not statistically signifi-
cant (27.1% vs 14.8%; P = .31).
The results of this study provide evidence that both
standing orders protocols and computerized reminders to
physicians are effective strategies to increase rates of
inpatient pneumococcal vaccination. The evidence is also
compelling regarding the superiority of a standing orders
protocol relative to computerized reminders to physi-
cians. The standing orders approach resulted in success-
ful vaccination of 98% of eligible consenting patients
admitted to the ward as opposed to only 23% of similar
patients admitted to the computerized reminder ward.
These results were deemed sufficient to terminate this
study and to institute a pneumococcal vaccination stand-
ing orders protocol on all general medicine wards at the
The results of this study are consistent with those of
previously published studies investigating the use of com-
puterized reminders to physicians to increase rates of
inpatient pneumococcal vaccination, with achieved vacci-
nation rates of 14% to 44%.18,20,22Although the design of
computerized reminders to physicians may be related to
the degree of their success in initiating pneumococcal
vaccination, even the most aggressive, sophisticated, and
user-friendly designs have achieved vaccination rates of
only 35.8%.22The relative noncompliance of physicians
with computerized reminders regarding pneumococcal
vaccination remains unexplained, but it has been suggest-
ed to be due to long-established habits of preferentially
vaccinating patients in the outpatient setting, exaggerated
physician fear of hypersensitivity reactions, lack of knowl-
edge concerning vaccine efficacy, difficulty confirming
previous vaccination history, and the competing concerns
of other pressing complex issues of inpatient hospitaliza-
tion.18,22Whereas the promise of the easy sustainability of
computerized physician reminder systems will undoubt-
edly continue to drive investigations related to the design
and implementation of effective computerized inpatient
vaccination strategies, it is clear that further investigation
of associated physician noncompliance is warranted.
Although this investigation was not a randomized
clinical trial, we believe that the comparability of age, gen-
der, ethnicity, and admitting diagnosis among the patients
strongly suggests that there was little bias relative to the
admission of any group of patients to each of the three
study wards. This conclusion is further supported by the
similarity of prior pneumococcal vaccination rates and
current vaccine acceptance rates among patients on the
two interventional wards. Provider bias was also consid-
ered unlikely given that multiple attending physicians and
residents provided care during the 4-month period on
each of the three study wards, although there was no
crossover of staff among the three wards. Furthermore,
patient assessments for inclusion, patient education and
consent procedures, and intervention activation were the
responsibility of a few pharmacists and were applied uni-
versally and consistently to all patients on the intervention
wards. Yet, it is prudent to note that the possibility
remains that some unmeasured difference in patients or
providers may have occurred and served to bias the
The standing orders protocol used in this study
used a pharmacist for patient screening and activation of
a standing order, which was found to be a highly effective
means of initiating the vaccination process. This strategy
is consistent with a recent position paper published by the
American College of Physicians and American Society of
Internal Medicine that advocated an increased role for
pharmacists in the immunization process.25Pharmacists
are skilled at medication counseling and have previously
been demonstrated to be especially effective at screening
and identifying candidates for vaccination and as immu-
nization educators.24,26In fact, 30 states currently allow
pharmacists to administer immunizations, although this is
not currently permitted by New York state law.25Our pro-
gram was sustainable by assigning the screening, con-
sent, and standing orders activation responsibilities to the
already existing pharmacy staff and was thus cost-neutral.
Screening within 72 hours of admission was acceptable to
patients and extended the window of opportunity to initi-
ate vaccination prior to discharge, as opposed to waiting
until the time of patient discharge. Although the use of a
computerized clinical information system facilitated
patient screening and undoubtedly helped to minimize
unnecessary patient revaccination, the standing orders
protocol could successfully stand alone without it. This
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IMPROVING INPATIENT PNEUMOCOCCAL VACCINATION RATES
standing orders protocol has demonstrated continued and
sustained efficacy, with approximately 99.5% of all eligible
consenting medical inpatients receiving pneumococcal
vaccination during the past 2 years.
It is also apparent that there is an opportunity to
increase rates of inpatient pneumococcal vaccination by
reducing refusal rates among patients who are eligible to
receive the vaccine. The data from this study suggest that
approximately 30% of eligible patients refuse vaccination,
primarily because they do not perceive themselves at risk
for pneumococcal disease. This occurred despite individ-
ual patient education sessions using the vaccine informa-
tion sheets that are currently available. Further research
is warranted to identify educational materials and meth-
ods that can be used to effectively communicate the risk
of pneumococcal disease to patients.
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